Free Form 63 - North Carolina

North Carolina Industrial Commission
IC File #

NOTICE TO EMPLOYEE OF PAYMENT OF COMPENSATION WITHOUT PREJUDICE (G.S. §97-18(d)) OR PAYMENT OF MEDICAL BENEFITS ONLY WITHOUT PREJUDICE (G.S. §97-2(19) & §97-25)
The Use of This Form Is Required Under the Provisions of the Workers' Compensation Act

Emp. Code # Carrier Code # Carrier File # Employer FEIN

(
Employee's Name Address City State Zip Employer's Name Employer's Address Insurance Carrier Carrier's Address City Policy Number City

)

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Telephone Number State Zip

( -

) -

M
Sex

( F

) / /

State Zip

Home Telephone

Work Telephone

(

)

-

(

)

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Social Security Number

Date of Birth

Carrier's Telephone Number

Fax Number

TO EMPLOYEE (TO DEPENDENT(S) OR NEXT OF KIN IN CASES OF DEATH): This is to inform you with regard to your claim for injury on / / (date) (Specify body part(s) involved):

occupational disease as of

/

/

(date) (Specify condition(s) and body part(s) involved):

death on

/

/

(date)

TO EMPLOYER/CARRIER: FILL OUT ONLY THE APPLICABLE SECTION 1 OR 2 BELOW NOTE: THE FOLLOWING ARE FOR INFORMATIONAL PURPOSES ONLY AND DO NOT CONSTITUTE AN AGREEMENT SECTION 1: INDEMNITY BENEFITS Payments of workers' compensation benefits, both indemnity (money) and medical, will be made without prejudice to later deny your claim or Defendants' liability. Compensation may be continued during the investigation of your claim. The investigation may take up to 90 days, with a possible 30 day extension. During this period, Defendants may admit liability; contest your claim or Defendants' liability; or by Defendants' lack of action, waive the right to contest your claim. The date on which Defendants first had written or actual notice of this claim was Disability began on / / / /
(date)

(date) and the first payment of compensation is being mailed on

/

/

(date) .

Subject to verification, employee's average weekly wage was $

, which results in a weekly compensation rate of $

SECTION 2: MEDICAL BENEFITS ONLY (PAID WITHOUT PREJUDICE, NOT SUBJECT TO 90-DAY REQUIREMENT IN SECTION 1 ABOVE) Payment of medical compensation is expressly being made without prejudice to Defendants to later deny the compensability of your claim. In the event you miss more than 7 days of work, you must notify your employer or carrier because you may be entitled to additional benefits. Completion of this section (Section 2) does not constitute an agreement to pay indemnity (money) benefits to you under G.S. §97-18(d). The date on which Defendants first had written or actual notice of this claim was / /
(date).

/
SIGNATURE OF EMPLOYER OR CARRIER/ADMINISTRATOR TITLE

/
DATE

SELF-INSURED EMPLOYER OR CARRIER MAIL TO: FORM 63 8/1/08 PAGE 1 OF 1 NCIC - CLAIMS ADMINISTRATION
4335 MAIL SERVICE CENTER

FORM 63

RALEIGH, NORTH CAROLINA 27699-4335 MAIN TELEPHONE: (919) 807-2500 HELPLINE: (800) 688-8349 WEBSITE: HTTP://WWW.IC.NC.GOV/